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CPT codes, descriptions and other data only are copyright 2007
American Medical Association (or such other date of publication of CPT).
All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental
Terminology, (CDT) (including procedure codes, nomenclature, descriptors
and other data contained therein) is copyright by the American Dental
Association. © 2002, 2004 American Dental Association. All rights reserved.
Applicable FARS/DFARS apply.
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For any item to be covered by Medicare, it must: 1) be eligible for
a defined Medicare benefit category, 2) be reasonable and necessary for the
diagnosis or treatment of illness or injury or to improve the functioning
of a malformed body member, and 3) meet all other applicable Medicare
statutory and regulatory requirements. For the items addressed in this
medical policy, the criteria for "reasonable and necessary" are
defined by the following indications and limitations of coverage and/or
medical necessity.
For an item to be covered by Medicare, a written signed and dated order
must be received by the supplier before a claim is submitted. If the
supplier bills for an item addressed in this policy without first receiving
the completed order, the item will be denied as not medically necessary.
INITIAL COVERAGE:
A single level continuous positive airway pressure (CPAP) device (E0601) is
covered if the patient has a diagnosis of obstructive sleep apnea (OSA)
documented by an attended, facility-based polysomnogram
and meets either of the following criteria (1 or 2):
1) The apnea-hypopnea index (AHI) is greater than
or equal to 15 events per hour, or
2) The AHI is from 5 to 14 events per hour with documented symptoms of:
a) Excessive daytime sleepiness, impaired cognition, mood disorders, or
insomnia; or,
b) Hypertension, ischemic heart disease, or history of stroke.
If a claim for a CPAP device (E0601) is submitted and the criteria above
have not been met, it will be denied as not medically necessary.
For the purpose of this policy, polysomnographic
studies must be performed in a facility based sleep study laboratory, and
not in the home or in a mobile facility. These labs must be qualified
providers of Medicare services and comply with all applicable state
regulatory requirements.
For the purpose of this policy, polysomnographic
studies must not be performed by a DME supplier. This prohibition does not
extend to the results of studies conducted by hospitals certified to do
such tests.
If there is discontinuation of usage of an E0601 device at any time, the
supplier is expected to ascertain this, and stop billing for the equipment
and related accessories and supplies.
CONTINUED COVERAGE BEYOND THE FIRST THREE MONTHS OF THERAPY:
Continued coverage of an E0601 device beyond the first three months of
therapy requires that, no sooner than the 61st day after initiating
therapy, the supplier ascertain from either the beneficiary or the treating
physician that the beneficiary is continuing to use the CPAP device.
If the above criterion is not met, continued coverage of an E0601 device
and related accessories will be denied as not medically necessary.
ACCESSORIES:
Accessories used with an E0601 device are covered when the coverage
criteria for the device are met. If the coverage criteria are not met, the
accessories will be denied as not medically necessary.
The following table represents the usual maximum amount of accessories
expected to be medically necessary:
A4604 – 1 per 3 months
A7027 - 1 per 3 months
A7028 – 2 per 1 month
A7029 – 2 per 1 month
A7030 – 1 per 3 months
A7031 – 1 per 1 month
A7032 - 2 per 1 month
A7033 – 2 per 1 month
A7034 - 1 per 3 months
A7035 - 1 per 6 months
A7036 - 1 per 6 months
A7037 - 1 per 3 months
A7038 - 2 per 1 month
A7039 - 1 per 6 months
A7046 – 1 per 6 months
Quantities of supplies greater than those described in the policy as the
usual maximum amounts, in the absence of documentation clearly explaining
the medical necessity of the excess quantities, will be denied as not
medically necessary.
Either a non-heated (E0561) or heated (E0562) humidifier is covered when
ordered by the treating physician for use with a covered E0601
device.
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